Validation of the Pediatric NEXUS II Head Computed Tomography Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

OBJECTIVE

Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care.

DESIGN

Systematic mapping review and narrative synthesis.

DATA SOURCES

Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED.

ELIGIBILITY CRITERIA

Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury.

DATA EXTRACTION AND SYNTHESIS

We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis.

RESULTS

Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories.

CONCLUSION

Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study

PURPOSE

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran.

METHODS

The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes.

RESULTS

In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models.

CONCLUSION

The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria have higher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomography Validation Study

STUDY OBJECTIVE

We evaluated the emergency department (ED) providers' ability to detect skull fractures in pediatric patients presenting with blunt head trauma.

METHODS

This was a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomography (CT) validation study. Demographics and clinical characteristics were analyzed for pediatric patients. Radiologist interpretations of head CT imaging were abstracted and cataloged. Detection of skull fractures was evaluated through provider response to specific clinical decision instrument criteria (NEXUS or Canadian head CT rules) at the time of initial patient evaluation. The presence of skull fracture was determined by formal radiologist interpretation of CT imaging.

RESULTS

Between April 2006, and December 2015, 1,018 pediatric patients were enrolled. One hundred twenty-eight (12.5%) children had a notable injury reported on CT head. Skull fracture was present in most (66.4%) children with intracranial injuries. The sensitivity and specificity of provider physical examination to detect skull fractures was 18.5% (95% confidence interval 10.5% to 28.7%) and 96.6% (95.3% to 97.7%), respectively. The most common injuries associated with skull fractures were subarachnoid hemorrhage (27%) and subdural hematoma (22.3%).

CONCLUSION

Skull fracture is common in children with intracranial injury after blunt head trauma. Despite this, providers were found to have poor sensitivity for skull fractures in this population, and these injuries may be missed on initial emergency department assessment.

EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW

Objective:

To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19.

Data sources:

Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded.

Data synthesis:

61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review.

Conclusions:

It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital

OBJECTIVES

To assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice.

METHODS

All paediatric (<17 years) patients with head injuries presenting to Frimley Park Emergency Department (ED), England from 1 May to 31 October 2018 were prospectively screened by a nurse using a mandated electronic 'Head Injury Discharge At Triage' questionnaire (HIDATq). We determined which patients underwent CT of brain and whether there was a clinically important intracranial injury or re-presentation to the ED. The negative predictive value of the screening tool was assessed. We determined what proportion of patients could have been sent home from triage using this tool.

RESULTS

Of the 1739 patients screened, 61 had CTs performed due to head injury (six abnormal) with a CT rate of 3.5% and 2% re-presentations. Of the entire cohort, 1052 screened negative. 1 CT occurred in this group showing no abnormalities. Of those screened negative, 349 (33%)/1052 had 'no other injuries' and 543 (52%)/1052 had 'abrasions or lacerations'. HIDATq's negative predictive value for CT was 99.9% (95% CI 99.4% to 99.9%) and 100% (95% CI 99.0% to 100%) for intracranial injury. The positive predictive value of the tool was low. Five patients screened negative and re-presented within 72 hours but did not require CT imaging.

CONCLUSION

A negative HIDATq appears safe in our ED. Potentially 20% (349/1739) of all patients with head injuries presenting to our department could be discharged by nurses at triage with adequate safety netting advice. This increases to 50% (543/1739), if patients with lacerations or abrasions were given advice and discharged at triage. A large multicentre study is required to validate the tool.

Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach

BACKGROUND

Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools.

METHODS

Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful.

RESULTS

Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice.

CONCLUSIONS

The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.